Raleigh, N.C. — If the panoply of issues facing the General Assembly every year were a zoo, the Medicaid health insurance program for the poor and disabled would be the snarling, nearly $14 billion beast that makes all of the other critters nervous.

So, maybe it shouldn't be a surprise that, during the first four months of this year's legislative session, discussions about making another run at taming Medicaid have been relegated mainly to early morning budget meetings and back-room discussions.

That is likely to change in the coming weeks.

"Both chambers say they're committed to staying here until we get it done," said Sen. Tommy Tucker, R-Union, one of several legislators who have floated proposals in the state House and Senate to remake Medicaid.

Lawmakers have one more week until "crossover," a hectic period during which both chambers scramble to meet a key legislative deadline for non-budget items. After that, the pace of work settles down, and legislators turn their attention to crafting the $21 billion state budget that will govern state operations beginning July 1. In general, lawmakers hope to finish their work for the year by early July, but sessions often drag into August and can go later.

That would give the General Assembly three months – give or take – to change how Medicaid operates.

Q&A: Medicaid basics
"We can't afford it if we don't get better cost controls in place," Tucker said, pointing to figures that show more than 20,000 people had been added to the Medicaid rolls this year.

In all, Medicaid covers roughly 1.8 million people in North Carolina, more than half of them children.

With the exception of mental health, North Carolina's current Medicaid program pays providers on a fee-for-service basis, meaning a doctor or hospital is paid for each individual procedure or treatment provided. State taxpayers pick up about 25 to 30 percent of the cost of the program, with the federal government paying the rest.

Generally speaking, lawmakers of all political stripes and Gov. Pat McCrory believe the state should move toward a capitated system under which a network of providers would take on the responsibility of caring for a patient in exchange for a flat fee. If the patient's health care costs less than the flat fee, the providers would make money. If the patient ended up costing more, the providers would lose money.

This shift in the risk would make budgeting for the program easier. Instead of budget swings based on how sick recipients were, how many services they used and vagaries involved in billing, the state would have to worry only about how many people were eligible for the program.

"There are some of us who believe that reforming Medicaid is a requirement for us to have predictability overall in the budget. I am definitely one of those," Senate President Pro Tem Phil Berger said. "The difference is that different members have different approaches on how to do that."

Two approaches dominate discussion

During the last legislative session, those "different approaches" boiled down into two different camps. One, championed by McCrory and senior House lawmakers, would prod local groups of doctors and hospitals to create accountable care organizations. The downside of the ACO approach is that it would take years to make the transition as ACOs came together and would likely require more hands-on management.

Senate leaders have typically looked for a quicker transition that would rely more heavily on existing managed care organizations.

The divide is not absolute. Tucker, for example, says he leans toward "provider-led" ACOs, while Rep. Justin Burr, R-Stanly, has championed measures that look much more like the turnkey managed care approach.

That standoff loomed over the 2014 legislative session, souring budget negotiations and leading to increasingly testy public sniping until the topic was dropped for the year.

"We really need to look beyond that," said Rep. Nelson Dollar, R-Wake, who has been a leading champion of the ACO approach.

To boil the fiendishly complicated reform debate down to ACO vs. managed care is an oversimplification, Dollar said.

"More fundamental is how do you structure the incentives to truly help bend the cost curve," he said.

In other words, how does the state structure a program to give doctors, hospitals, patients and administrators motivation to save money when they can?

While those questions are definitely being asked, they are still, at least for the moment, packaged in the ACO vs. managed care context. Doctors, hospitals and other providers continue to talk up the ACO approach.

"We already treat Medicaid patients every day," said Cody Hand, a lobbyist for the North Carolina Hospital Association.

Hand describes the ACO plan put forward by McCrory and tweaked by House lawmakers last year "the best outcome we can see."

That option still has the backing of the McCrory administration.

"DHHS continues to have the same vision for Medicaid reform that Gov. McCrory put forward more than a year ago: A provider-led, patient-centered health care model that fosters partnership and accountability between providers and patients," said Alexandra Lefebvre, a spokeswoman for the Department of Health and Human Services. "This model puts patients first by focusing on better health outcomes versus paying only for services."

On the other side of the argument, managed care companies say that no state has gone to an exclusively ACO model and that they should be able to compete for business in the state.

"We think a competitive marketplace will serve both taxpayers and Medicaid recipients better," said Taylor Griffin, the front person for N.C. Medicaid Choice, a group backed by health insurers Aetna, Amerigroup, AmeriHealth Caritas, UnitedHealth Group and WellCare.

Allowing managed care companies to play a bigger role, Griffin said, would allow for cooperative arrangements between providers that could focus on giving care and insurers, which could handle billing and administrative functions.

No matter their positions, lobbyists such as Hand and Griffin say that advocates have been speaking with lawmakers but don't have a clear indication of if, when or how the General Assembly will settle on a Medicaid solution.

"What I have seen over the past few weeks is a lot more legislators engaging in the issue and trying to learn more," Griffin said.

Tucker said he hopes that lawmakers in both chambers can get together on a single approach and roll out a bill that includes the basics of a compromise right from the start.

Asked about the flurry of Medicaid legislation already filed, Tucker said, "They're placeholder bills, in my opinion, waiting for the final document to be drafted."

Sam NadaApr 28, 2015

View quoted thread

Another reason socialized medicine doesn't work: UK forced to trim $31B from it's healthcare budget. This results that the threshold for non-lifesaving surgeries will be raised and 20k jobs lost and several hospitals closed.Canada has deteriorating facilities, overburdened doctors, and long hospital waiting lists is clear. wait time elective surgery 4 yrs, pap smear 5 mo., mammogram 8 mo. Canada controls health care costs the same way Britain and Russia do: by denying modern treatment to the sick and letting the severely ill and old die. Socialized medicine = death.

— Posted by Abrams Gunner

And yet they are both ahead of the US in overall quality of health care, with much lower cost. Picking out specific problems with certain countries ignores other countries that are consistently better than the US, and also does nothing to fix the low quality of care here. Still waiting after all these decades for the GOP to offer a solution, to anything other than helping the rich get richer.

Sam NadaApr 28, 2015

"Nice to point out the US facts but how do they compare with those countries that have socialized medicine?"

Many if not most of the countries ahead of us in the ratings listed in that article have socialized medicine. You've picked on one specific weakness of the Canadian system, as if that is the entire story for all countries with universal health care. It's not. Here's another comparison between the US and other 1st world countries with universal health care:

Abrams GunnerApr 28, 2015

Another reason socialized medicine doesn't work: UK forced to trim $31B from it's healthcare budget. This results that the threshold for non-lifesaving surgeries will be raised and 20k jobs lost and several hospitals closed.Canada has deteriorating facilities, overburdened doctors, and long hospital waiting lists is clear. wait time elective surgery 4 yrs, pap smear 5 mo., mammogram 8 mo. Canada controls health care costs the same way Britain and Russia do: by denying modern treatment to the sick and letting the severely ill and old die. Socialized medicine = death.

Abrams GunnerApr 28, 2015

View quoted thread

"We spend more per capita because we provide more healthcare to our citizens...What you call "sub-par" care is still better than the care you would receive in a lot of countries."

You are utterly wrong. There is no measure by any reputable agency that shows the US has better overall health care than other 1st world countries.

http://www.nejm.org/doi/full/10.1056/NEJMp0910064

"It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?"

— Posted by Sam Nada

Nice to point out the US facts but how do they compare with those countries that have socialized medicine?

Sam NadaApr 28, 2015

"We spend more per capita because we provide more healthcare to our citizens...What you call "sub-par" care is still better than the care you would receive in a lot of countries."

You are utterly wrong. There is no measure by any reputable agency that shows the US has better overall health care than other 1st world countries.

http://www.nejm.org/doi/full/10.1056/NEJMp0910064

"It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?"

Abrams GunnerApr 28, 2015

View quoted thread

I'm not wrong. Many independent organizations and studies have shown the US health care system to be the most expensive per capita in the world, by far, and with worse outcomes than any 1st world country.

http://ucatlas.ucsc.edu/spend.php

The CIA site shows the US as 42nd in the wold in life expectancy at birth:https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.htmlOur health care cost per capita is the highest of any country by a wide margin:http://en.wikipedia.org

Citing one personal example does not refute the simple fact that we have failed badly in the past to provide good health care to all our citizens, and have paid dearly for it. How many have died prematurely due to not having access to preventive care? Good care for the elite and sub-par care for 10's of millions is a tragedy and a crime. Universal care is not optional. Improving the ACA is the only way forward. If you don't believe it offer a better solution.

— Posted by Sam Nada

We spend more per capita because we provide more healthcare to our citizens. That is the price you pay if you want fast access to quality healthcare. Have you ever had to wait three months to see a doctor here in the US?. Medical professional salaries are much more than other countries. "Orthopedic surgeons in Canada make less than half the $440,000 average net income of colleagues in the States while doing more procedures".

What you call "sub-par" care is still better than the care you would receive in a lot of countries.

Sam NadaApr 28, 2015

I'm not wrong. Many independent organizations and studies have shown the US health care system to be the most expensive per capita in the world, by far, and with worse outcomes than any 1st world country.

http://ucatlas.ucsc.edu/spend.php

The CIA site shows the US as 42nd in the wold in life expectancy at birth:https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.htmlOur health care cost per capita is the highest of any country by a wide margin:http://en.wikipedia.org

Citing one personal example does not refute the simple fact that we have failed badly in the past to provide good health care to all our citizens, and have paid dearly for it. How many have died prematurely due to not having access to preventive care? Good care for the elite and sub-par care for 10's of millions is a tragedy and a crime. Universal care is not optional. Improving the ACA is the only way forward. If you don't believe it offer a better solution.

Abrams GunnerApr 28, 2015

View quoted thread

"Like the working people are taxed to death"

No, like much better overall health with much lower cost. Here's a graph that shows a comparison to life span versus health care costs by country. Paying a high price for early death is a very good description of the US health care system. The ACA is a step towards universal health care, with cost control, and is exactly what we need.

"For every one it helped I'd be willing to say it harmed 20"

You may be "willing to say" anything. Here are the facts:

http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/

— Posted by Sam Nada

Your graph is wrong according to the cia.gov website. For every article you cite I can find one to refute it (for the sake of argument).

Another Obamacare fact is that 80% that sign up qualify for subsidies that are funded by the taxpayers.

Socialized medicine is not good. I know from personal experience. Have you ever had socialized medicine or a loved one that did. If not, you have no idea what you are talking about. All you know is what you read. Waiting 3 months for a doctors appointment when you have cancer is a death sentence. We currently do not have that here in the US and God willing we never will.

Sam NadaApr 28, 2015

Sam NadaApr 28, 2015

"Like the working people are taxed to death"

No, like much better overall health with much lower cost. Here's a graph that shows a comparison to life span versus health care costs by country. Paying a high price for early death is a very good description of the US health care system. The ACA is a step towards universal health care, with cost control, and is exactly what we need.